can we do to manage it?

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1 Femoroacetabular impingement: What is it, does it matter and what Click to edit Master title style Click to edit Master subtitle style can we do to manage it? Joanne Kemp PhD, APA Sports e:

2 INTRODUCTION The hip is commonly injured in young and middle-aged people Hip commonly placed into positions of impingement in activity (eg: 12-14% of all football injuries) Walden 2005, Ekstrand 2011

3 INTRODUCTION In susceptible people, this can result in impingement related pain (and pathology)

4 What morphology is typically seen in FAI? Normal Cam Pincer scoop on NOF, acetabular anteversion bony growth on anterior/superior neck of femur Acetabular retroversion Deep socket

5 FAI - Pincer

6 FAI - Cam

7 Is cam lesion a pathology? Incidence 25% of population (Ganz et al 2003) 25-50% men, but 0-10% women 89% athletes, but 9% non athletic controls 88% bilateral deficits 23% of these painful 42% with cam also have pincer (Allen et al 2009) Many people live with cam for a lifetime without symptoms.

8 Cam is NOT a pathology (Pollard 2010, Bardakos & Villar 2009, Byrd & Jones 2009, Croft et al 1991) Cam creates FAI pathology when repetitive impingement (or major traumatic impingement) occurs Impingement usually occurs in flexion and IR (+/- adduction) Cam lesion not FAI FAI refers to pain and pathology that occurs when cam lesion impinges on acetabular structures in susceptible people

9 Likely abnormal premature contact between femur and acetabulum leading to soft tissue pathology seen in FAI Femoro-acetabular Impingement Labral pathology Chondropathy 95% of patients with cam also have chondral and labral pathology

10 Is there a standard definition of FAI?

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12 Warwick Consensus agreement For a patient to be diagnosed with FAI Syndrome, must have 1. Positive imaging findings 2. Symptoms of hip or groin pain 3. Signs of FAI, including physical impairments and positive impingement tests.

13 Imaging findings for FAI

14 Imaging Remember imaging is only indicative of morphology. Many people have positive imaging findings without symptoms. To measure cam or pincer morphology, plain x-ray (AP pelvis and Dunn 45 view) is adequate and is the gold standard. To measure associated pathology (eg: labral, chondral), cross-sectional imaging (eg: MRI) is the best option but not perfect

15 Typical presentation seen on imaging

16 What morphology is typically seen in FAI? Normal Cam Pincer scoop on NOF, acetabular anteversion bony growth on anterior/superior neck of femur Acetabular retroversion Deep socket

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18 How to measure cam lesion α

19 What does the alpha angle mean? Alpha angle > 60 = presence of cam lesion Alpha angle >78 = pathological cam deformity (associated with end stage OA) Agricola 2014 OAC Alpha angle >83 = OR 9.7 (4.7 to 19.8) for end stage OA within 5 years CHECK cohort Agricola 2012 ARD For every degree increase in alpha angle, increased risk of end stage OA by 5% Chingford cohort, Nicholls 2011 AR, Thomas 2014 OAC...larger alpha angles = greater risk of hip OA

20 Signs and symptoms of FAI

21 What are signs and symptoms in FAI? Patient-reported outcomes Physical impairments Impingement tests

22 Symptoms of FAI

23 Where is the pain coming from? % of hips with FAI had labral and/or cartilage lesions at surgery Clohisy 2013, Philippon 2009, O Donnell 2010 Labrum contains nociceptors Dhollander % greater likelihood of cartilage damage if cam FAI present = early hip OA Kemp 2014 Synovitic pain recognised in OA Wenham 2010, Scanzello 2012 Two thirds patients with FAI have synovitis Clohisy 2013 Abutting bone may be pain source Subchondral bone in early knee OA contains pain molecules Ogino 2009 Maybe bony impingement in hip causes pain?

24 How long has it hurt?

25 Signs of FAI

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27 Results 22 studies included (819 people, mean age range years, clinical and radiological FAI) Moderate quality 12 studies non-surgical, 10 studies surgical 17 studies ROM (12 goniometer, 5 simulated) 6 studies strength (6 HHD, 2 EMG, 1 muscle volume) 6 studies functional tasks (no. of strides, squat depth, dynamic balance, pelvic ROM)

28 Summary of results Hip joint ROM did not differ symptomatic FAI v control participants. Hip muscle strength and dynamic balance on 1 leg reduced FAI v control participants. Hip joint ROM did not change between pre-intervention and post-intervention time points. Hip muscle strength improved significantly from pre-hip to post-hip arthroscopy in a single case series.

29 Do physical impairments predict outcomes in people with chondrolabral pathology?

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31 Results In people with chondrolabral pathology Greater hip flexion range was associated with better QoL outcomes (r ; p<0.05) Greater hip adduction strength was associated with better QoL outcomes (r ; p<0.05)

32 Is the trunk impaired? Chondrolabral patients had reduced performance in side bridge test compared to controls on surgical (p=0.002) and non-surgical (p=0.001) sides. Side bridge predicted ihot-33 (Adj r 2 = to 0.481) anterior pelvic tilt = acetabular retroversion IR@90 and FADIR ROM Trunk control can alter impingement Trunk control can alter impingement People with impingement pathology have reduced trunk control bilaterally Trunk control may be an important target

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34 Hip arthroscopy group vs controls (peak squat depth) Greater hip adduction (mean difference 2.7, 95% CI 0.7 to 4.8 ) Greater knee valgus (4.0, 95% CI 1.0 to 7.1 ) Greater pelvic obliquity during single leg stance (1.2, 95% CI 0.1 to 2.3 ). Deficits in single leg squat performance exist May increase hip joint impingement and perpetuate symptoms.

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36 RESULTS SUMMARY Patients with hip chondrolabral pathology have bilateral impairments on functional performance tests months after unilateral hip arthroscopy compared to controls. In patients with chondrolabral pathology, greater strength in hip abduction and adduction were associated with better functional performance. Better performance in the side bridge and hop tests were associated with better PROs

37 Overall evidence for signs of FAI (physical impairments) Patients with FAI are impaired pre-op or no-op and remain impaired post-op compared to controls Impairments include 1. reduced hip muscle strength (sex specific), 2. reduced functional task performance, 3. increased impingement in SL squat, 4. reduced trunk function, 5. reduced dynamic balance, 6. alterations in gait, 7.??ROM (poor ROM = poor outcomes).

38 Special tests

39 FADIR (Flexion, Adduction, IR) Sensitivity ranges 94 to 99 Specificity ranges 5 to 25 FADIR is a good test to rule people out as not having FAI (low risk of false negatives) BUT FADIR is not a good test to rule people in as having FAI (high risk of false positives)

40 FABER (Flexion, Abduction, ER) X Sensitivity ranges 42 to 60 Specificity ranges 18 to 75 FABER is a poor to fair test to rule people out as not having FAI (high risk of false negatives) AND FABER is a poor to fair test to rule people in as having FAI (high risk of false positives)

41 Flexion IR overpressure Sensitivity ranges 70 to 98 Specificity ranges 8 to 43 Flex/IR OP is an good to excellent test to rule people out as not having FAI (low risk of false negatives) BUT Flex/IR OP is a poor to fair test to rule people in as having FAI (high risk of false positives)

42 Summary: What is FAI?

43 Does FAI matter?

44 camfai Time line of lifespan 5-20 years of hip patient Agricola 2013, 2013, Nicholls 2011 Hip OA

45 cam develops years Agricola AJSM 2014, Siebenrock 2011, Pollard 2010 FAI, labral, chondral (35 y.o) Kemp BJSM 2013 camfai Hip OA Pain, 5-20 poor years PROs, physical impairments Agricola 2013, 2013, Nicholls 2011 Painful FAI +/- labral (25 y.o) Kemp BJSM 2012 Clinical hip OA (40+ y.o) McCarthy 2011, Tuominen 2009

46 Previous studies have shown that larger cam lesions (alpha angle >83) are associated with 10-fold increased risk of hip osteoarthritis (OA) and progression to hip arthroplasty within 5 years Agricola 2013

47 Patient-reported outcomes FAI Controls FAI*** Pre-op* 18 mths** 30 mths** Pain ADL QoL *Hinman et al, BJSM, 2014 n=30 **Kemp et al, BJSM, 2014 n=72 ***Clohisy AJSM, 2014 n=1076

48 Does FAI matter? Yes!! While most people with cam morphology do not develop FAI, for those that do, the impact is enormous Quality of life scores similar to people with end stage hip OA. Young and middle aged people with large family and work commitments Unable to exercise = big consequences for general health Increased risk of end stage hip OA and THA

49 What can we do to manage FAI?

50 What is the evidence for surgery?

51 Surgical RCTs of hip arthroscopy (registered) Trial Country Sample Size Interventions UK FASHIoN UK (Warwick) 344 Arthroscopic surgery vs physiotherapy Aus FASHIoN Australia 120 Arthroscopic surgery vs physiotherapy FAIT UK (Oxford) 120 Arthroscopic surgery vs physiotherapy FIRST Canada and Finland 220 Arthroscopic surgery vs arthroscopic washout HIPARTI Norway, Sweden 140 Arthroscopic surgery vs Belgium, Canada and diagnostic arthroscopy Australia US Army WA USA 60 Arthroscopic surgery vs physiotherapy Planned Reporting unknown

52 Determine outcomes for hip arthroscopy for patients with and without osteoplasty for FAI.

53 Conclusions: Large positive within-subject effect sizes for improved pain and function for up to 10 years (no femoral osteoplasty) and 3 years (femoral osteoplasty) Outcomes for hip OA appear worse but unclear Adverse events were minimal (7% of participants) in 12 studies); transient neuropraxia (83%). Methodological quality poor and thus limits confidence in results

54 1. Determine outcomes for hip arthroscopy for hip OA, 2. Compare outcomes between no OA and OA, and 3. Examine progression to THA in hip arthroscopy for hip OA

55 Conclusions: Patients with more severe hip OA had worse outcomes of pain and function than those with less severe OA or no hip OA. Factors influencing outcomes: Age; JSN on x-ray. Effect of chondral pathology unclear and conflicting. Progression to THA occurred within 2 years in people with severe hip OA Quality of the included studies was moderate at best. Effects of modifiable factors on people with hip pain and co-existing hip OA are unknown.

56 What is the impact of chondral pathology on outcomes?

57 Results: Summary Chondropathy (early hip OA) is prevalent in young to middle aged people with hip pain Prevalence increases with age Severe chondropathy is associated with worse outcomes months post-op Majority of outcomes do not improve over time 40% greater likelihood of chondropathy if FAI or labral pathology present

58 Overall evidence for surgical intervention Within-subject patient reported outcomes do improve post-op compared to pre-op While outcomes improve, these patients remain impaired compared to healthy controls Patient outcomes do not improve beyond 12 months Older age, JSN, severe chondropathy all = worse outcomes Chondropathy is prevalent and increases with age FAI, labral pathology and chondropathy do co-exist No RCT evidence yet..

59 Non-surgical treatment of FAI

60 Current evidence for non-surgical treatment of FAI

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62 Results N=15, 2 groups No difference between groups for change score for HOS (pain and function) (trend favoured control) No difference between groups for physical measures (trend favoured MTEX for strength and hop) Underpowered to find difference between groups Care when interpreting these findings Although called a pilot, primary outcome was pain and function Unable to draw conclusion about effectiveness of PT from this study

63 Primary outcome: feasibility of full scale trial; Secondary outcome: pain and function

64 Results: Secondary outcome All PROs improved in physiotherapy intervention group and difference in change score always favoured physiotherapy over control group No changes were statistically significant (small numbers included in this pilot study) Mean HOOS-S HOOS-P HOOS-A HOOS-Sp HOOS-Q ihot-33 PRO Control Physiotherapy Intervention Preliminary evidence that semi-standardised physiotherapy treatment regime improves pain and function post arthroscopy??

65 Treatment for FAI: An impairment based model

66 What should a physiotherapy program for FAI include?

67 Goal of treatment = optimise hip joint loads Hip strength Trunk strength Functional and balance retraining Sports specific retraining ROM optimization Education

68 Hip strength

69 Flexion Especially women with pathology Abduction For both sexes especially pathology Adduction For all patients +/- pathology Extension, ER Especially women with pathology

70 Strength training considerations Consider strength, power and endurance capacity of muscles Use strength and conditioning principles Non periodised training (varied between sessions) Strength heavy resistance, low reps, several sets Endurance low resistance, high reps, one set to fatigue, replicate functional positions Avoid impingement - Pain free positions

71 Trunk strength

72 Progressive strength trunk Retrain both sides Watch overactivity in hip flexors (care with crunches and sit ups) Focus on endurance

73 Function and balance

74 Progressive functional and balance retraining Retrain both sides Specific to sports Focus on strength and endurance Restore full load requirements

75 Optimise ROM

76 Optimise ROM (especially flexion) Soft tissue techniques Manual therapy techniques Muscle activation Techniques for lumbar spine and pelvis Take care as flexion limitation may be protective

77 Education

78 Education: Position of impingement Activity and position modification for 90% (ADL) to allow full activity for 10% (sport)

79 Education: Pathology and prognosis For post surgical and non surgical patients.. Assume FAI patients have early hip OA and treat accordingly Lose weight if needed General CV training vital: find a sport that they enjoy and is safe for them to do (cycling, running, swimming, walking ) They will have flare ups of symptoms Must be prepared for maintenance program that includes strength, balance, neuromotor control They will improve but will not be the same as a healthy age-matched control

80 Education: Treatment options Physiotherapy treatment does not have good efficacy. As non-surgical treatment providers, we need to provide patients and surgeons with a high quality, efficacious treatment alternative to surgery this is generally lacking

81 Take home message: non surgical treatment Physiotherapy treatment does not yet have Level 1 RCT evidence Physiotherapy treatment may follow an impairment-based model Impairments to address include 1. Hip muscle strength 2. Trunk muscle strength 3. Function, balance 4. Cardiovascular training 5. ROM optimisation 6. Education

82 Final take home message What is FAI? FAI is clinical diagnosis = presence of symptoms, signs and morphology in people with hip and groin pain Does it matter? Yes! For affected people, impact on QOL & PA enormous, with increased risk of end stage hip OA and THA How can we treat it? Surgical and non-surgical options. Neither have level 1 evidence yet to support effectiveness. Surgery no longer funded. Best practice physiotherapy treatment should target known impairments to optimise joint loads and improve outcomes

83 @JoanneLKemp e: